Why does "schizophrenia" persist?

I sometimes wonder if anyone in mental health really believes in the idea of an illness called schizophrenia. Sure there are true believers in psychiatry like Jeffrey Lieberman and E.F. Torrey who will happily claim that there is a distinct brain disease the word connotes. Their advocacy (such as in Lieberman's recent "Shrinks" and Torrey's ever popular family manual "Surviving Schizophrenia") is a big part of how the diagnosis has come to have broad currency.

But once you get interested in schizophrenia, it doesn't take long for the whole edifice to look a bit crumbly. For almost as long as schizophrenia has been around there has been contention about it as an entity. This contention is not just an expression of "phenomenologic relativism" (Lieberman's angry charge), it is a respectable doubt about whether the construct of schizophrenia is a valid object for scientific study. It has been articulated most elegantly by Richard Bentall and Mary Boyle, who both conclude that schizophrenia is not a valid construct. When you try to find examples of people refuting their position, it's hard to come up with much of substance. Thus, a chapter on the construct of schizophrenia in Daniel Weinberger's big textbook on schizophrenia says this:

The diagnostic criteria currently used (ICD - 10 and DSM - IV - TR) can be considered provisional and arbitrary constructs with some face validity that meet the objective of facilitating international communication and research. (p.9)

Meanwhile, in their Very Short Introduction to Schizophrenia, Chris Frith and Eve Johnstone acknowledge Mary Boyle's long and detailed book, but they dismiss it by saying simply "we are not convinced" (this comment appears in a Further Reading section at the back of their book).

Given all the articulate doubt, and its less than convincing refutation, why has the schizophrenia label survived? When this question has been asked by critically minded scholars, the answer has tended to be "money and professional esteem". David Pilgrim endorses a version of this argument in an essay in "Reconstructing Schizophrenia", and in "Madness in Civilization", Andrew Scull points out that "chronic conditions are chronically profitable" (p.393).

There can be no doubt that the financial and professional interests of psychiatry and pharmaceutical companies play a role in the survival of schizophrenia, but this explanation cannot be the whole story. Both motivations played a role in the brief flurry of interest in Paediatric Bipolar Disorder (an ugly controversy documented well in multiple posts by One Boring Old Man), but the APA, cogent of its many problems, ultimately moved to stop that diagnosis getting into DSM-5. That is not proof that the APA's mechanisms for self regulation are good enough, but it does suggest the need for another ingredient in order for a disorder to become as successful as schizophrenia.

What is missing in the economic account of schizophrenia's survival is the fact that, validity concerns notwithstanding, there is a way in which the diagnosis is very convincing; on the face of it many people who meet criteria for schizophrenia seem to be seriously unwell and many of them will testify to that fact. This is something that schizophrenia's many critics frequently seem to miss. It is largely (though not entirely) missing from the BPS's Understanding Psychosis document, and it is missing from the writing of Bentall, Boyle, and others, who tend to view their work as a foundation for moving away from an "illness model" of what they refer to as "psychological distress".

In fact, even the ultimate collapse of schizophrenia would not be tantamount to evidence that there are no illnesses in the space the diagnosis used to occupy. In a staunchly critical book "Schizophrenia is a Misdiagnosis", the psychiatrist C.Raymond Lake argues that schizophrenia cannot be distinguished from severe psychotic mood disorders, and also provides a long list of disorders which can get diagnosed as schizophrenia (see below).

Perhaps then the persistence of schizophrenia can partly be attributed to a case of a divided opposition. All of schizophrenia's critics can be seen as wanting to carve away chunks from the existing construct by placing people into alternative categories. For some these chunks are "psycho-social distress" (i.e. not ill at all), for others they should go into more precise medical categories (i.e. ill with something doctors actually understand). To some extent these players in the debate speak at cross purposes; they might even be construed as competing over territory:

Schizophrenia as shrinking territory.

By far the most vocal and high profile critics are psychologists who want to reframe schizophrenia as a form of psychosocial distress (they want to expand the purple section in the diagram). This effort is unlikely to be entirely successful because, even with skepticism about the DSM construct, many people's intuitions are that there is something illnessy about the experiences which commonly attract the diagnosis. This group tends to be reluctant to acknowledge the presence of any psychiatric illness (witness the BPS report-writing guidelines which sought to exclude even the words "illness" or "disorder").

Schizophrenia's medical critics believe that progress will come as more and more people currently in the "bucket" of schizophrenia are given a correct medical or psychiatric diagnosis (as the yellow section expands). This quieter territory expansion is constantly ongoing, with new "subgroups" of schizophrenia emerging periodically, associated with specific physiological characteristics (a very recent example is here). When these subgroups are sufficiently well understood they raise an interesting problem; are they still a form of schizophrenia, or (given that the DSM definition of schizophrenia has an exclusion clause saying that symptoms must not be due to the direct physiological effects of a [...] general medical condition.) have they become something else?

It is this ongoing uncertainty which surely accounts for the continued plausibility of schizophrenia in the psychiatric and public imaginations. Yes there are many people who fall in the purple and yellow overlaps of my venn diagram, but there are others (how many?) who currently do not. The hypothetical construct schizophrenia is a testament to the suspicion that, when everything tumbles out, there will be a well understood bio-psycho-social process giving rise to the symptoms in DSM-5. Should that process be sufficiently well understood, it might be what we end up giving the name "schizophrenia" 100 years from now.

Alternatively, the purple and yellow sections may keep expanding, finally squeezing schizophrenia out of the picture altogether. Only an omniscient being can currently say how much of the middle circle will be left in the end. For the time being no amount of political activity seems sufficient to quell people's suspicion that when psychiatry talks about schizophrenia, it is talking about something worth naming. 

Medicating History

The history of the discovery of neuroleptic drugs for psychosis is often (more often than not?) used for professional-political ends. I recently read Jeffrey Lieberman's book on the history of psychiatry, in which he provides a description of the first psychiatric use of chlorpromazine. If you take it at face value you get the impression that the new drug was immediately impressive because of its dramatic impact on the symptoms of psychosis per se. Here's Lieberman's description (with some underlining of parts I found particularly striking):

On January 19, 1952, chlorpromazine was administered to Jacques L., a highly agitated twenty four- year-old psychotic prone to violence. Following the drug’s intravenous administration, Jacques rapidly settled down and became calm. After three steady weeks on chlorpromazine, Jacques carried out all his normal activities. He even played an entire game of bridge. He responded so well, in fact, that his flabbergasted physicians discharged him from the hospital. It was nothing short of miraculous: A drug had seemingly wiped away the psychotic symptoms of an unmanageable patient and enabled him to leave the hospital and return to the community. (p.164)

Compare that to a 2007 piece by Thomas Ban, which is sufficiently similar that it could have provided the model for Lieberman's description, but for a few subtle differences (again with extra underlining):

Jacques Lh., a 24-year-old severely agitated psychotic (manic) male was the first psychiatric patient to receive CPZ; he was administered 50 mg of the drug, intravenously, at 10 am, on January 19, 1952. The calming effect of CPZ was immediate but since it lasted only a few hours several  treatments were required before the patient’s agitation was controlled. Repeated administration of the drug caused venous irritation and perivenous infiltration. Hence, on several occasions barbiturates and electroshock were substituted for CPZ. Nonetheless, after 20 days of treatment, with a total of 855 mg of CPZ, the patient was ready “to resume normal life.” (p.496)

It's amazing how word choice and subtleties of description can paint radically different pictures of the same set of events. I know nothing else about Jacques L/Lh. What were the nature of his psychotic symptoms? To what extent was he actually manic? Was it psychosis, mania or his agitation that was most affected by the chlorpromazine? Finally, what happened to Jacques, and what did he think of the new medication he had tried?

The Pleasures of Delusion

Would it be somehow crass or offensive to talk more about pleasure when we talk about clinical delusions? We tend to think of delusions (defined now in the DSM-5 as "fixed beliefs that are not amenable to change") as being principally aversive experiences, and so they seem to be. The idea that you are being persecuted, that you might die imminently, that your family have been replaced by imposters; these are all terrifying sounding notions. Apart from being frightening in content, delusions have the added misery of rarely being shared. If everyone else believes you are being persecuted too, at least you don't have to deal with the profound disorientation of never being taken seriously.

But despite the undoubted terror of holding certain beliefs, and the loneliness of being the only person you know who does, it would be hard to imagine anyone ever having them if there wasn't something about them that we sometimes needed.

And in fact we have become accustomed to thinking of delusions as a defence, that is as being at least preferable to something worse. For Freud they were elaborate ways of getting away from homosexual longings. You start with a forbidden love, and how you go about denying it determines what sort of delusion you end up with. Freud accounted for delusions of persecution (”I do not love him I hate him” gets projected to “he hates me”), "Erotomania" (”I do not love him I love her”), delusions of jealousy ("it is not I who love the man, she loves the man") and megalomania ("I do not love at all-I don’t love anyone”). So systematic was Freud that his equation hung around for close to a century (and still holds sway in some quarters).

More recently delusions have been construed as one way of managing negative emotions. An individual who tends to attribute experiences to the external rather than internal realm, the argument goes, may be interpret feelings of badness in terms of a persecutory world rather than as being about themselves. There is a whole family of theories which take issue with this "attributional" account of delusions. These tend to invoke multiple factors, including most frequently perceptual anomalies and some sort of over-hasty style of reasoning. However even less emotion centric theories seem to gesture toward a motivational component. Thus the famous "jumping to conclusions" bias (the tendency, to make a decision on the grounds of less evidence), which seems fairly robustly associated with delusional ideation, has been itself accounted for in multiple ways. Is it a response to a "need for closure", or of an "intolerance of uncertainty"?

In a related vein, the philosopher Lisa Botolotti recently suggested that delusional beliefs could represent a sort of epistemic damage limitation. Better that you entertain a single false belief than suffer a broader psychic overwhelm and become unable to believe anything. This is the delusion as adaptive, as the fuse which can be allowed to blow in order to stop the whole edifice burning down. What these accounts all share is the suggestion that delusions are the least worst of several bad options. Put it that way and we focus on the unpleasantness of what is being defended against, but what about the appeal of holding a delusional belief?  It begs the question of what role our everyday beliefs hold for us. Hang around delusions research for long enough and you start to ask why anyone believes anything.

This is what brings me to the question of pleasure. Think of how pleasurable it is when you know the answer and no-one else does, when you finally figure it out, when everything suddenly makes sense. Addressing herself to the difficult question of what constitutes a satisfactory explanation, psychologist Alison Gopnik described "explanation as orgasm". Think, she suggests, of the way children (those "little scientists") seek endlessly for explanations, would they really be doing that if it wasn't a lot of fun? Richard Feynman spoke about "The pleasure of finding things out". As a research physicist, Feynman really was in the process of "finding things out", but don't the rest of us get pleasure from thinking we understand things better than we do? Anyone who has spent time in a bar with some politically disgruntled bore will recognise the peculiar glee that accompanies the "conspiratorial whisper". It is the pleasure of seeing through it all; of knowing what other people don't know. Might delusions sometimes afford something of that pleasure?